Stenosing tenosynovitis is more common than you might think even though few of us can pronounce it. Even its common name, “trigger finger,” sounds like something that might affect gunslingers. Regardless of what you call it, trigger finger is pretty easy to recognize. One or more fingers get stuck in a bent position as if to pull a trigger. People over the age of 40 with a history of diabetes or rheumatoid arthritis are especially at risk but it can occur in people of all ages.
Manish R. Gupta, MD, is a board certified plastic surgeon with significant experience dealing with trigger finger. “The exact cause of trigger finger is unknown,” he says, “but the treatment, for me, is pretty straightforward. With that said, it should be emphasized that the surgery is technically demanding because it requires working in close proximity to the nerves and blood supply of the hand. There is some degree of risk of permanent damage noted in medical literature—though I have not seen it or dealt with it—so, I encourage finding a surgeon who is highly qualified and experienced.”
Trigger finger involves the tendons and pulleys in the hand that bend the finger. Dr. Gupta points out that there are strong muscles in the forearm but our hands are designed to be nimble and sensitive rather than strong. Tendons connect the muscles of the forearm with the bones of the fingers. “With a small movement of the muscle we can get a great degree of movement in the fingers,” says Dr. Gupta. “From a biomechanical perspective, it’s a fantastic system “
The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the fingers, the pulleys form tunnels through which the tendons glide. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that promotes easy gliding inside the pulleys. When you bend your fingers, the tendons glide back and forth through these guides in much the way that line runs through the guides on a fishing rod.
When one of these pulleys or guides becomes inflamed, it swells and develops a knot or thickening in the tendon. The knot passes through the pulley as the finger bends but gets stuck and won’t allow the finger to straighten out again. “No X-rays are needed to diagnose trigger finger,” says Dr. Gupta. “You can feel the knot or nodule at the base of the finger. When the finger is stuck for an hour or more, it can be quite painful.”
Dr. Gupta tells of Maria, a 47-year-old auto worker at a local plant. “The small and ring fingers of her right hand tended to get stuck in the bent position,” he says. “Fortunately, someone at the factory recognized that something could be easily done to fix the problem. Maria was concerned that she might have to take a lot of time off from work, go through a painful surgery, and then deal with extensive rehabilitation. I diagnosed her problem even more easily than usual because it triggered right in front of me.”
There are two standard treatments for trigger finger—steroid injections and surgery. “Steroids have a success rate of about 30%,” says Dr. Gupta, “but the surgery is so easy, benign, and successful that I don’t even recommend steroids anymore. Some people have a very strong aversion to surgery, though, so we sometimes have to take that route first.”
The surgery requires only a one centimeter incision, under local anesthesia, at the base of the finger. “I find the pulley and cut the obstruction,” says Dr. Gupta. “Then, I ask the patient to move the finger. If it doesn’t trigger, we have been successful. I also take the occasion to examine the pulley to make sure the problem was not caused by a tumor on the tendon—which would be extremely rare. Only one additional day off from work is required because of the open wound. I like to schedule the surgery for Thursdays so the patient can have Friday off and then be back on the job Monday.”
Some patients don’t have to return to work at all. One of Dr. Gupta’s patients was a 3 ½-year-old girl. “Her mom works at a hospital,” he says, “When her baby was only six months old she noticed that both of her thumbs were cocked and wouldn’t straighten out. With congenital triggering, you normally wait until the child is about three. The issue may have resolved on its own by then. In this case, it hadn’t. They girl had been taken to a doctor who forced her thumbs open—which resulted in a great deal of pain and the triggering recurred anyway. Mom is intelligent and caring and the child is bright. The little girl knew that something needed to be done but she didn’t want to go through the pain again—especially if the problem was just going to come back. Surgery offers a permanent solution and we tried to make it as acceptable as possible for her.”
When performing trigger finger surgery for children, Dr. Gupta uses general anesthesia rather than a local. “I use microsurgery,” he says, and it important for the patient to hold still and be compliant. Children may have difficulty being either still or compliant when faced by the unfamiliar and apparently threatening prospect of surgery. We try to be very sensitive to what they are going through. They walk back to the operating room with their mother and can bring along a favorite stuffed animal. Then they are partially sedated by being given a flavored gas. They can choose bubble gum or grape or other flavors they may like. When they are sleepy, the IV is inserted. When the child wakes up, she has no recollection of what happened. I use dissolving stitches so they don’t even have to have them pulled out after the wound heals. The whole procedure only takes 30 for adults or about 45 minutes for children because of the difference in the administration of anesthesia.”
Dr. Gupta says the emotional well being of children is very important. “I love working with children but they need special care. Kids are not just little adults,” he says.
If you have trigger finger, find a qualified physician. But don’t bother with Doc Holliday. He pulled a different kind of trigger. Besides, he was a dentist.June 1, 2015